BANK FORM

1. DIASPORA BANKING ACCOUNT APPLICATION FORM
DIASPORA
BANKING
ACCOUNT
APPLICATION
FORM
www.kcbgroup.com SMS: 22522 0711 087 000 / 0732 187 000 Whatsapp: 0711 087 087 contactcentre@kcbgroup.com
Regulated by the Central Bank of Kenya
BANK
FOR OFFICIAL USE ONLY:
CUSTOMER ID: _______________________________________ ACCOUNT NUMBER: __________________________________
CLIENT DETAILS (Please complete in block letters and Tick appropriately)
Title: Mr./Mrs./Dr./Ms./Prof Name:
Amount in Figures:
ID/Passport No.: Date of Issue: Expiry Date:
Nationality: KRA Pin No.:
Marital Status: Single
Divorced
Married
Widow/Widower
Gender: Male Female
Date of Birth: .....................................................................
Current Residential Address:
City: Country:
Telephone:(+)
Sources of Funds:
Email:
Employer’s Name or Business Name if Self employed:
Nature of Business: Designation/Job Title:
Employed Self Employed
USD GBP
Other:
Student Details
Monthly Income: EURO ZAR AUD CAD
Name of Institution:
Student Id No.: Graduation Date:
Minor Details
Telephone: Email:
Next of Kin/Alternative Contact - Name:
Contact
Name of child
Birth Certificate/Notification number:
Relationship:
Date of Birth:
1
AFFIX PHOTO
HERE
ACCOUNT DETAILS
YES NO If Yes, Account Number: ..........................................................................................
KES
Account Currency:
Type:
Customer Signature: ........................................................................................................... Date: ................................................................................
Do you have an account with KCB?
I hereby apply for an account as follows:
USD GBP EURO AUD CAD CHF ZAR
Individual Joint (Complete separate Individual forms)
Account: Currrent Transactional Simba Savings Student Cub

2. INSTRUCTIONS TO ORDER (Tick where applicable)
Issue Debit Card (Where Applicable) YES NO
If Yes, Primary Mobile No.:
Register for KCB Mobi Bank?
Automatic Sending of SMS/EMAIL Alerts (Tick appropriately)
YES NO
www.kcbgroup.com SMS: 22522 0711 087 000 / 0732 187 000 Whatsapp: 0711 087 087 contactcentre@kcbgroup.com
Regulated by the Central Bank of Kenya
2
YES NO
Salary
Register for KCB Internet Banking? YES NO
Receive Transaction Authorization Numbers (TAN) via
Would you like us to accept your electronic instructions from provided Email of Fax
(This is mandatory for any email/fax instructions from Account holder)
Email Mobile
All Credits (Specify amount): ........................................... All Debits (Specify amount): ...................................................
BOTH
CUSTOMER DECLARATION (Please place your initials next to the box)
Signed in the presence of (Notary Public/Kenyan Embassy Stamp & Signature): ................................................................................
Date: ................................................................................
I hereby authorise the Bank to register me for the above indicated services. By signing on this form, I agree that I have read,
understood and accept the General and Specific Terms and Conditions of these services provided at https//ke.kcbgroup.com/le-
gal/ , as may be ammended from time to time, including the authority and indemnity for Electronic Instructions provided
therein, and agree to be bound by the same.
I confirm that the information given above is true to the best of my knowledge.
I hereby authorize the Bank to disclose any information relating to the account(s) to any Credit Reference Agency, any other
institution or third party as it deems necessary.
Mode of signing: (If Joint): Any/Both/All to Sign/Others - Specify: .....................................................................................................................
Signature: Date: .................................................................................
FATCA - (If you live in USA) Foreign Account Tax Complaince Act (FACTA)
Are you a US Resident?
Are you a US Citizen?
Are you holding a US Permanent Resident Card (Green Card)
Were you born in the US?
Have you granted Power of Attorney or Signatory authority to a person with a US address?
Have you granted Power of Attorney or Signatory authority to a person with a US address?
Do you have a US Residential Address?
Do you have a correspondence, C/O or Hold Mail address in the US?
Do you have a standing order to a US Bank Account?
Do you have a US Telephone Number?
Are you FATCA compliant?
YES NO
Note: Debit cards issued to joint accounts ONLY if “ANY TO SIGN”
By signing on this form I request you to open an account in my/our names. I agree that I have read, understood and accepted the
Term and Conditions of this account, provided at https//ke.kcbgroup.com/legal/ and agree to be bound by them.

3. Valid Identification documents obtained and verified Foreign Individual - Letter from Employee/Student ID
FOR BANK USE ONLY
CUSTOMER INFORMATION CHECKLIST
Name of Sales Staff/Agent:
Branch Name: Branch DAO:
Staff Number:
Immediate Sales Supervisor:
Name of staff making the sale referral:
Sector: Target: Customer Type: Risk Class:
Sales Code (12x):
Staff Number:
Sales Code (12x):
www.kcbgroup.com SMS: 22522 0711 087 000 / 0732 187 000 Whatsapp: 0711 087 087 contactcentre@kcbgroup.com
Regulated by the Central Bank of Kenya
3
Customer information obtained
Pep Check Manadate signatures obtained (where applicable)
Blacklist checked Operating Tools required indicated
Financial statements Sources of Income/Funding obtained and verified
KRA Pin provided FATCA information collected
Photographs obtained/captured and authenticated
Authorising Official’s Signature: ............................................................................ Branch Stamp: ...................................................................
(And Signature Number)